Breast conservative surgery and whole breast radiotherapy versus breast conservative surgery and IORT: surgical opinion.

BACKGROUND: To define the possibility of intraoperative radiation therapy (IORT)'s application on clinical practice and point out the problems observed by Verona Breast Unit. METHODS: Among the patients of the Breast Unit at Azienda Ospedaliera Universitaria Integrata of Verona, treated between July 2015 and June 2017, were identified 459 patients undergoing breast conserving surgery for a carcinoma, followed by IORT in 77 cases or by Whole Breast Radiotherapy (WBRT) in 382 cases. The data of WBRT group were analyzed considering IORT eligibility criteria to identify a sub-group of eligible patients, for whom we evaluated the diagnostic process that had led to exclusion from IORT. RESULTS: In WBRT group 184 patients (48%) had a ductal NOS infiltrating carcinoma, of which 64 cases (16.8%) were eligible for IORT. Other 79 patients of WBRT group (21%) presented DCIS, of which only 27 were in the American Society for Radiation Oncology "suitable" group for IORT. Considering the results of the preoperative exams, or rather needle biopsy and MRI scan, 55 patients of 64 (85.9%) resulted unsuitable for IORT, while nine patients (14.1%) could be eligible. CONCLUSIONS: IORT's major limits are: the restricted eligibility criteria, especially on histology; the need of a complete execution of preoperative exams and the technical limits of these exams. ASTRO suitable group, including small diameter, low-grade DCIS, might be used to extend the eligibility criteria. A multidisciplinary approach might improve the preoperative study, so the use of IORT in clinical practice.

Dose tracking assessment for image-guided radiotherapy of the prostate bed and the impact on clinical workflow.

BACKGROUND: The cumulative dose was compared with the planned dose among fourteen patients undergoing image-guided, intensity-modulated radiotherapy of the prostate bed. Moreover, we investigated the feasibility of adding dose tracking to the routine workflow for radiotherapy. METHODS: Daily cone beam computed tomography was conducted for image-guided radiotherapy, and weekly cumulative delivered doses were calculated for dose tracking. Deformable image registration was applied to map weekly dose distributions to the original treatment plan and to create a cumulative dose distribution. The dose-volume histogram (DVH) cut-off points for the rectum and bladder and the planning target volume (PTV), were used to compare the planned and cumulative delivered doses. The additional time required by the departmental staff to complete these duties was recorded. RESULTS: The PTV coverage of the delivered treatment did not satisfy the expected goal for three patients (V98% >98%). In another three patients, the DVH cut-off point for the bladder was higher than the limits, while for the rectum, treatment was as expected in all cases (two patients failed both their bladder constraints and the PTV coverage). Overall, four patients did not satisfy one or more criteria at the end of their treatment. CONCLUSIONS: A well-defined strategy for dose tracking assessment is feasible, would have minimal impact on the workload of a radiotherapy department, and may offer objective information to support radiation oncologists in making decisions about adaptive procedures.

Role of perfusion CT in the evaluation of functional primary tumour response after radiochemotherapy in head and neck cancer: preliminary findings.

OBJECTIVE: To report the initial results of a prospective study aimed at evaluating the CT perfusion parameter changes (∆PCTp) of the primary tumour after radiochemotherapy (RCT) in head and neck cancer (HNC) and to correlate with positron emission tomography (PET)/CT response. METHODS: Eligibility criteria included HNC (Stage III-IV) candidates for RCT. Patients underwent perfusion CT (PCT) at baseline and at 3 weeks and 3 months after treatment. Blood volume, blood flow, mean transit time (MTT) and permeability surface (PS) product were computed. Moreover, PET/CT was performed at baseline and 3 months after treatment. The ∆PCTp were evaluated between baseline and 3-week/3-month evaluations, whereas PET/CT response was based on the maximum standardized uptake value changes according to the European Organization for Research and Treatment of Cancer criteria. RESULTS: Between July 2012 and July 2015, 25 patients were enrolled. A significant reduction of all CT tumour perfusion parameters (PCTp) was observed from the baseline to after RCT (p < 0.001). Specifically, a significant reduction was shown at 3 weeks for all PCTp except MTT (from 6.18 to 5.14 s; p = 0.722). Differently, a significant reduction of all PCTp (p < 0.001) including MTT (from 6.18 to 2.24 s; p = 0.001) was shown at 3 months. Moreover, the reduction of PS resulted in a significant prediction of PET/CT response at 3 months (p = 0.037) with the trend also at 3 weeks (p = 0.099) at the multivariate analysis. CONCLUSION: Our preliminary findings seem to show that almost all PCTp are significantly reduced after RCT, whereas PS seems to come out as the strongest factor in predicting the PET/CT response. ADVANCES IN KNOWLEDGE: This article provides information on the potential useful role of PCT in evaluating tumour response after both early and late RCT.

No benefit of adjuvant Fluorouracil Leucovorin chemotherapy after neoadjuvant chemoradiotherapy in locally advanced cancer of the rectum (LARC): Long term results of a randomized trial (I-CNR-RT).

BACKGROUND AND PURPOSE: To evaluate the effect of adjuvant chemotherapy (ACT) in locally advanced rectal cancer (LARC) after neoadjuvant chemoradiation (NACT-RT). The study was funded by the Italian National Research Council (CNR). METHODS: From September 1992 to January 2001, 655 patients with LARC (clinically T3-4, any N) treated with NACT-RT and surgery, were randomized in two arms: follow-up (Arm A) or 6 cycles of ACT with 5 fluorouracil (5FU)-Folinic Acid (Arm B). NACT-RT consisted of 45Gy/28/ff concurrent with 5FU (350mg/sqm) and Folinic Acid (20mg/sqm) on days 1-5 and 29-33; surgery was performed after 4-6weeks. Median follow up was 63·7months. Primary end point was overall survival (OS). RESULTS: 634/655 patients were evaluable (Arm A 310, Arm B 324); 92·5% of Arm A and 91% of Arm B patients received the preoperative treatment as in the protocol; 294 patients of Arm A (94·8%) and 296 of Arm B (91·3%) underwent a radical resection; complete pathologic response and overall downstaging rates did not show any significant difference in the two arms. 83/297 (28%) patients in Arm B, never started ACT. Five year OS and DFS did not show any significant difference in the two treatment arms. Distant metastases occurred in 62 patients (21%) in Arm A and in 58 (19·6%) in Arm B. CONCLUSIONS: In patients with LARC treated with NACT-RT, the addition of ACT did not improve 5year OS and DFS and had no impact on the distant metastasis rate.